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Living in the US

Introduction
Healthcare in the US

The US healthcare system is complex and difficult to navigate, especially for foreigners who are unfamiliar with the country. This section explains how it works, along with the related federal requirements and responsibilities for exchange visitors.

Part 1 Healthcare facilities
Part 2 Healthcare providers
Part 3 Feeling ill at work
Part 4 Health insurance system
Part 5 Health insurance terms
Part 6 Important remarks

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Part 5 Health insurance terms
Healthcare in the US

The US healthcare system involves many concepts and terminologies that may be confusing to foreigners. Familiarize yourself with the common terms used in the US healthcare industry.

Coinsurance: The portion or percentage of the remaining cost the insurance company pays after you pay the deductible. As an example, your plan has a coinsurance of 80% per illness or injury after the deductible is met. You visited a physician two times and are charged $60 for each visit. With a $100 deductible, you can file a claim of $16 ($60 x 2 visits - $100 deductible = $20; 80% of $20) from your insurance company.

Copayment (or copay): Some medical insurance plans require a copay, which refers to the mandatory fixed amount that you need to pay for each medical bill. Typically, copays do not count toward any deductible. As an example, your plan has a deductible of $100 per illness or injury and a copay of $10 for each visit. You visited a physician two times and are charged $60 for each visit. You can file a claim of $10 ($60 x 2 visits - $100 deductible - $10 copay) after your second visit.

Deductible: The amount you pay for any covered health care services before your insurance plan starts to pay. As an example, your plan has a $100 deductible per illness or injury. You visited a physician two times and are charged $60 for each visit. You can file a claim of $20 from your insurance company.

Drugs: "Prescription drugs" refers to drugs that you purchase from a special counter in a pharmacy, and which require medical prescriptions from a physician in order to be dispensed; over-the-counter (OTC) drugs can be purchased with no medical prescription. Most prescription drugs have two names: the brand name and the generic name. Generic drugs typically cost less than brand name drugs. If prescription drugs are not (or partially) covered by your health plan, you may request the doctor to prescribe generic drugs, if available, to save cost.

Exclusions: The conditions for which your insurance company will not pay. As an example, cosmetic plastic surgery procedures are generally “excluded” (meaning not covered by insurance).

Premium and medical benefit: “Premium” (usually paid monthly) refers to the fee you pay to the insurance provider to maintain coverage. “Medical benefit” refers to how much your insurance company will pay for the treatment.

Medical evacuation and Repatriation of remains: The former refers to the amount of money the insurance company will pay to transport you to your home country for care if you become very sick or injured in the US. The latter refers to the amount of money the insurance company will pay to return your remains to your home country if you pass away in the US.

Preauthorization: Some health plans require “preauthorization.” If applicable and you didn’t obtain prior approval before treatment, your insurance isn’t promising that it will pay 100% of the costs.

Preferred Provider Organization (PPO): A separately organized network of healthcare physicians and hospitals in the US contracted by your insurance provider. If applicable, using a provider in the PPO network of your insurance company may reduce your out-of-pocket costs.

Primary Care Physician (PCP): PCP refers to the doctor you visit most often to receive medical care for common non-life-threatening medical conditions. Some health plans require patients to specify a PCP as the first point of contact for healthcare and get the PCP’s referral before seeing a specialist.

Specialist: Specialists are doctors who have completed advanced education and training in a specific field of medicine. Some health plans require “referrals” from the PCP to see specialists for the costs to be covered.

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Part 6 Program guidelines
Healthcare in the US

1 Requirements. The DOS requires qualified health insurance and the program requires “entry to exit” health insurance coverage for participants and their J-2 dependents. During programs, ensure that the health insurance is in effect at all times with no interruption. If the initial purchase of the insurance doesn’t last through the US departure date, be sure to submit the updated period and valid proof at least two weeks before the expiration date. Refer to PDF #13 for such requirements.

2 Changes. Any changes to the previously purchased insurance require immediate reporting and completion of the amendment process with PDFs #13-15 and the coverage period updated at least 72 hours prior to changes. Any changes to the US exit date require the health insurance’s coverage period to be updated at least 72 hours prior to changes or immediately if changes have happened.

3 Added protection. Health insurance and travel insurance aren’t the same thing. Health insurance generally only covers medical emergencies while travel insurance covers “when things go wrong while traveling”, e.g., trip cancellation/interruption, baggage/trip delay, loss/damaged luggage. Find out whether travel insurance is included as part of the health insurance plan purchased and/or credit card used to pay for flights and/or other travel expenses. Also, adventure sports (e.g., rock climbing) are generally not covered by health insurance. Some health insurance plans offer travel protection and adventure sports coverage for extra charges. If it is necessary, purchase extra coverage for added protection.

4 School-sponsored insurance. Some schools offer a school-sponsored insurance at no cost to their students attending exchange programs abroad. Find out whether your trip is covered and whether the school-sponsored insurance meets the minimum requirements as per PDF #13. If not, purchase qualified health insurance on your own.

5 Consequences. Failure to carry the qualified insurance and provide valid proofs is considered a serious violation of the federal regulations which will result in immediate termination of the participant’s exchange visitor status, affiliation with FUSIA, and enrollment in the Exchange Visitor Program. Such actions will require the participant’s immediate departure from the US, given the revocation of your “J” status.

www.fusia.net/ushealthcare